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UNIVERSITY OF CHICAGO DCAM OUTPATIENT PH
DSH140191 INGALLS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
INGALLS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140191
Entity Address
ONE INGALLS DRIVE
HARVEY, IL 60426
Medicare Provider Number
140191
Participating Start Date
9/22/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
UNIVERSITY OF CHICAGO DCAM OUTPATIENT PH
Pharmacy Address
5758 S. MARYLAND AVE.
MC0010
CHICAGO, IL 60637-1426
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KURT E. JOHNSON, CEO
(708) 915-6101
Contract Pharmacy Representative
Christy Gorbach, Pharmacy Manager
(773) 255-7236
Signed By Date
7/17/2017
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